From the Guidelines
To clear an inpatient for electroconvulsive therapy (ECT), a comprehensive pre-ECT evaluation is essential, including a complete medical history, physical examination, and psychiatric assessment, as outlined in the practice parameter for use of electroconvulsive therapy with adolescents 1.
Pre-ECT Evaluation
The evaluation should include:
- A complete medical history to identify any potential medical contraindications or relative contraindications that require identification before ECT 1
- A physical examination to assess physiological parameters that may affect administration of ECT or anesthesia 1
- Laboratory investigations, such as complete blood cell count, differential white blood cell count, electrolyte levels, liver and thyroid function tests, urinalysis and toxicology screen, and electrocardiogram, as dictated by clinical assessment 1
- Neuroimaging, such as MRI or CT scan, if indicated by the patient's history or if not already completed as part of a workup for treatment-refractory depression 1
- A serum or urine pregnancy test for female patients to minimize potential risks if they are pregnant 1
Medication Management
- Review and optimize the patient's medication regimen, typically holding benzodiazepines for 24-48 hours before ECT as they raise seizure threshold, and adjusting anticonvulsants if possible 1
- Continue most antidepressants and antipsychotics, but consider holding MAOIs for 2 weeks prior to ECT 1
Anesthesia and ECT Administration
- Consult anesthesiology for pre-anesthetic evaluation, focusing on airway assessment and cardiovascular status 1
- Ensure NPO status (nothing by mouth) for at least 6-8 hours before the procedure 1
- Administer ECT in a specially designated area by a team of clinicians, including a psychiatrist, an anesthesiologist, and nursing staff experienced in the use of ECT 1
Informed Consent and Documentation
- Obtain informed consent after discussing risks, benefits, and alternatives with the patient and/or their legal representative 1
- Document the indication for ECT and that less invasive treatments have failed or are inappropriate 1
From the Research
Preprocedural Evaluation for ECT
To clear an inpatient patient for Electroconvulsive Therapy (ECT), several factors need to be considered, including underlying medical conditions and current medications.
- A review of the literature suggests that ECT is generally a safe and effective therapy, but some patient subgroups, such as those with certain cardiac conditions or history of cerebrovascular disease, require additional evaluation or, rarely, postponement of ECT 2.
- Chronic medical conditions should be optimized before undergoing ECT 2.
Medication Considerations
When evaluating patients for ECT, it is essential to consider potential interactions between psychotropic medications, anesthetics, and ECT.
- Tricyclic antidepressants (TCAs) and ECT can be combined safely and beneficially 3.
- More care is required when ECT is administered in the setting of a monoamine oxidase inhibitor (MAOI), especially the older irreversible varieties and in patients recently placed on MAOI therapy 3.
- The combination of antipsychotics and ECT is well tolerated, and may in fact be beneficial 3.
- Benzodiazepines have anticonvulsant properties that might interfere with the therapeutic efficacy of ECT, and their use during ECT may decrease seizure duration 4.
- Anticonvulsants may also impact the clinical outcomes of ECT, although the evidence is varied and contradictory 4, 5.
Safety of ECT with Anticoagulation
The safety of ECT in patients receiving oral anticoagulants has been assessed in several studies.